Karatekas educated on injury prevention and supported by fitness coaches are more likely to practise injury prevention

To determine the current perceptions and practices of top-level karate athletes concerning risk factors and injury prevention programme (IPP) implementation in training and competition. Out of 90 eligible countries (933 athletes) participating in the karate World Senior Championships (WSC) in Madrid 2018, 50 countries (55.6%) represented by 137 athletes (14.7%; 52 females and 85 males) responded to a structured questionnaire. Of the athletes responding, 45% reported that their national team did not conduct any measures to reduce injury risk (43% among females and 47% among males; p = 0.68). Kumite athletes (51%) were more likely to practise injury prevention compared to kata athletes (25%; p = 0.016). Of the respondents, 69%, 60%, 60% and 34% reported having no team doctor, fitness coach, massage therapist and physiotherapist, respectively. A greater proportion of athletes who had access to a fitness coach (part-time or full-time) engaged in injury prevention strategies (67% and 51%, respectively) than those who did not (35%; p = 0.031). Athletes who had received previous advice about injury prevention were more likely to practise injury prevention (58%) compared to the rest (21%; p < 0.001). The current study revealed that: i) almost half of the karatekas already benefited from an injury prevention programme, ii) injury prevention programmes were practised more frequently when there was a fitness coach among their coaching staff, iii) karatekas who had received education about injury prevention were more likely to practise injury prevention programmes.


INTRODUCTION
injury prevention practice by body part, and (iv) perceived injury risk factors.
The design of the survey took into consideration the authors' combined knowledge and experience of sports medicine and sports science in elite karate. The survey was pilot tested with 20 highlevel karate athletes (who did not participate in the WSC) before the start of the study. The received feedback and comments were taken into consideration and changes were made in response to these.

Survey analysis
Raw data were entered separately by DC and LP from paper questionnaires to Microsoft Excel and then double-checked case by case by MT. The data were analysed using the SPSS 22.0 program for Mac OS X (SPSS, Inc., Chicago, IL, USA). Crosstabs using chi-square tests were used to analyse proportions.

Survey information
Out of 90 countries (933 athletes) eligible to the survey languages, 50 countries (55.6%) represented by 137 athletes (14.7%; 52 females and 85 males) completed the questionnaire. However, 416 athletes did not volunteer and 380 could not be reached.

IPP overview and athletes' perception and attitude toward injury prevention
Of the athletes responding, 45% reported that their team had not conducted any preventive measures to reduce injury risks (43% among females and 47% among males (p = 0.68). Kumite athletes (51%)

Design
Cross-sectional study based on face-to-face surveys.

Survey
The survey was constructed in English, French, Slovak, and Spanish.
The questionnaire consisted of 15 questions (see online supplementary appendix Injury Prevention WKF questionnaire) with four sections: (i) injury prevention implementation overview, (ii) perceptions and attitudes towards injury prevention, (iii) perceived injury risk and   Injury prevention perception in elite karate athletes, the three most important risk factors for injury are presented in Figure 4.

DISCUSSION
This is the first study to directly observe the beliefs and considerations of IPP and provides insights into the perceptions of IPP in elite karate. The current results reveal that: i) 45% of the participating athletes reported that their team had not conducted any preventive measures to reduce injury risks, ii) injury prevention programmes were practised more frequently when the athletes had a fitness coach, iii) athletes who had received previous advice about injury prevention were more likely to practise injury prevention programmes, and iv) the main risk factors for injuries were thought to be 'too much training', 'lack of recovery time between competitions', and 'low muscle strength'. The findings of this study will help inform practitioners about the barriers and facilitators of IPP in elite karate.

IPP overview and athletes' perception and attitude toward injury prevention
In the present study, nearly half of the participating athletes reported that they had not conducted any preventive measures to reduce injury risks. Much of the research on IPP so far has focused on team sports, with player adherence identified as a key factor for IPP success [12]. However, the results of this study indicated that this low implementation rate could not be linked to players' adherence, as almost all of the respondents reported that an injury prevention programme is important to reduce injury occurrence and were positive or very positive towards injury prevention measures.
Whilst athletes are the intended health beneficiaries of IPP, team staff also play a key role in achieving the desired injury prevention [14]. In the present study, most respondents were not sup- O'Brien et al. [15] found that in football, fitness coaches were responsible for delivering the IPPs, while physiotherapists assisted with the supervision and correction of exercises.
The current study also shows that player education is a key factor and major point of divergence when it comes to practising compared to never practising injury prevention. Indeed, respondents who had received previous advice about injury prevention were nearly three times more likely to practise IPP compared to karatekas who had not received any advice. This aligns closely with the fact that education and communication of scientific evidence play an important role in convincing players about injury prevention benefits [8,12]. The were more likely to practise injury prevention compared to kata athletes (25%; p = 0.016). Among the respondents, 69%, 60%, 60% and 34% had no team doctor, fitness coach, massage therapist and physiotherapist, respectively. Athletes who had a fitness coach (part-time or full-time) employed better injury prevention strategies (67% and 51%, respectively) compared to athletes who did not have a fitness coach (35%; p = 0.031).
The availability of medical and technical staff in the teams and the relationship with injury prevention practice are presented in Table 1.
Athletes who had received previous advice about injury prevention were more likely to practise injury prevention (58%) compared to those who had not received any advice (21%; P < 0.001). As many as 88% of the participating athletes thought that injury prevention is important in karate, while 90% of respondents had a positive or very positive attitude towards injury prevention measures.
The perception and attitude of the karate athletes toward injury prevention are presented in Table 2.

Perceived injury risk and 'importance' of injury prevention according to body parts
Of the surveyed athletes, 54%, 50% and 43% responded that the ankle, knee, and head were the most frequently (frequently or all the time) injured body parts. Their perceived importance of injury risk according to body part is detailed in Figure 1.
The most important body parts that karate athletes think should be protected most are the thigh, knee and ankle. Participants' perceived 'importance' of injury prevention regarding body parts is presented in Figure 2.

Perceived injury risk factors
The perception about injury risk in competition compared to training is presented in Figure 3. Based on perceived rating of importance by findings suggest that team managers should ensure the availability of at least part-time fitness coaches and physiotherapists within their teams.

Perceived 'importance' of injury prevention according to body parts
A recent systematic review and meta-analysis on injury epidemiology in WKF karate indicated that the most commonly injured body parts were the head and neck, and the lower limbs [1]. Despite the fact that the 28 studies included in this meta-analysis were all from competitions (e.g. championships and tournaments), a similar distribution was reported by our respondents, with ankle, knee and head/face injuries perceived as the most frequent (without differentiating between training and competition). Interestingly, in the current study, athletes did not clearly distinguish between body parts when asked about their prevention priorities. It seems that karatekas have a relatively accurate picture of the injury epidemiology, yet do not make any clear differentiation when it comes to preventing injuries.
For them, all body parts seem nearly equally important. This is an interesting observation and may simply reflect that injury to any small body part (e.g. a broken finger) could stop the athlete from practising karate. Therefore, this is a point of reflection for clinicians. Should we focus on the most frequent/serious injuries for prevention, and ignore the rare ones, or should we consider any injury as a potential threat to the athletes' career and therefore consider prevention more broadly?

Perceived injury risk factors
The main perceived injury risk factors in the current study were: 'too high training load', 'too short recovery period between competitions', 'lack of muscle strength' and 'lack of flexibility'. This is consistent with Destombe et al. [3], who previously suggested that 'more time spent training each week' was associated with an increased risk of injury in karate. On the other hand, recent studies in football have indicated that lack of recovery between matches and high training load were perceived by the practitioners as the two main key extrinsic risk factors for injury [12,13]. Therefore, the monitoring of training load could appear as crucial in preventing injuries among elite karatekas. In karate, several methods using competition/training duration and heart rate or rating of perceived exertion to quantify the training load have previously been validated and could be a useful support for karate practitioners [16][17][18]. Nevertheless, this issue needs further investigations to verify whether the perception of the athletes turns out to be correct, i.e. that a high training load is actually associated with an increased risk of injuries.
'Lack of muscle strength and flexibility' was considered, in the current study, as a major perceived injury risk factor in karate. This aligns with the few studies focusing on IPP showing that muscle strength and flexibility were frequently assessed from screening tests in elite soccer to prevent non-contact injuries [12,13,19]. However, to date, no studies have documented an effect of flexibility training as prevention, and this finding in the present study refers to karate athletes' view. Indeed, this could be the nature of karate -with greater demands on flexibility than running sports or soccer. It would therefore be interesting to test the effects of an injury prevention programme including both eccentric resistance and flexibility exercises in elite karate.
Arriaza et al. [2] reported that the global injury incidence during

Limitations and considerations
There are some limitations to our survey. First, there is a gap concerning the level of some teams/countries, in which resources (e.g., equipment and staff numbers) will vary and will influence the knowledge, attitude and practices of teams. Second, only 137 karatekas par- This study provides knowledge about how karatekas perceive the injury prevention programmes. However, this knowledge and good intentions to use it do not guarantee adoption. [21] Key considerations are how these programmes will be delivered and by whom. As noted by O'Brien and Finch (7) and O'Brien and Donaldson (21), it will be essential to address all levels of the system when developing karate injury prevention programmes and their related implementation plans to identify potential barriers (e.g., lack of knowledge, time or programme acceptance) and facilitators to programme adoption.

CONCLUSIONS
The current study revealed that: i) almost half of the karatekas have already benefited from an injury prevention programme, ii) injury prevention programmes are more frequently practised when a fitness coach is present in the athlete's coaching staff, iii) karatekas who had received education about injury prevention were more likely to practise injury prevention programmes.